Jaundice

Question 1

pathway of haem metabolism?

Answer 1

1. Haem to unconjugated bilirubin + A- in spleen
2. Conjugation in liver
3. Excretion via GI tract

Question 2

UNconjugated bilirubin is…

Answer 2

INsoluble (binds albumin)

Question 3

conjugated bilirubin is…

Answer 3

soluble (so can be excreted)

Question 4

Causes of unconj. ↑ bili?

Answer 4

Overproduction (haemolysis)
Impaired liver uptake (DHx, rifampicin)
Impaired conjugation (Gilbert’s)
Neonatal

Question 5

Causes of conj. ↑ bili?

Answer 5

1) Hepatocellular dysfunction
- Hep, CMV, EBV, lepto, syphilis,
- DHx (eosinophilia + ↑ wbc + rash + ↑ T)
- alcohol, toxins
- AIH, mets, cirrhosis, sepsis, haema, a-1 def, Wilson’s, RHF, Budd-Chiari etc

2) Impaired excretion
- PBC, PSC, common duct stones, pancreatic CA, compression, cholangioCA choledochal cyst, biliary atresia
- DHx
- weird syndromes (Caroli, Mirrizi?)

Question 6

pale stools and dark urine?

Answer 6

CONJUGATED ↑ bili

Question 7

possible Ex findings in jaundice?

Answer 7

encephalopathy (flap)
lymph + hepato + spleno ↑
ascites
palpable GB

Question 8

what can cause decompensation in a stable patient with cirrhosis? (4)

Answer 8

1) sepsis
2) alcohol/DHx
3) HCC
4) GI bleed

Question 9

Ix in jaundice?

Answer 9

Urine
- bili & urobili (no urobili in obstructive)
Bloods
- FBC + clotting (function)
- film + reticulocytes + Coombs’ + haptoglobin (haemolysis, malaria, EBV)
- U+Es (AKI)
- LFTS (AST >1000 if viral)
- cultures and serology (lepto, hep)
US
- bile duct dilated if obstruction (GS, mets, pancreatic CA)
ERCP
- if dilated bile ducts and abnormal LFTs
MRCP/EUS
- if gallstones but no common duct stones
Liver biopsy
- if ducts normal
CT/MRI
- malignancy